Call for help! Creating an efficient emergency response protocol in an
outpatient imaging centerVilert Loving MD MMM, Shay Dupras RN BSN, Brian Johnston MD, Kristi Blackhurst RT, Joseph Rush RT, Mariann Figuli AAS ARRT
Banner MD Anderson Cancer Center, Division of Diagnostic Imaging, Gilbert, Arizona
Vilert Loving, MD MMMBanner MD Anderson Cancer Center, Gilbert, ArizonaEmail: [email protected]: https://www.bannerhealth.com/banner-md-anderson
Contact
1. Taylor MJ, McNicholas C, Nicolay C, et al. Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Qual Saf 2014; 23: 290-298.2. ACR Committee on Drugs and Contrast Media. ACR Manual on Contrast Media version 10.3. 2017.
References
In 2015, a patient at our Outpatient Imaging Center (OPIC) experienced an anaphylactic reaction to intravenous contrast. The CT technologist yelled for help. Multiple staff responded, though many were uncertain of their role in the response (Fig 1). Medication and supplemental oxygen administration was delayed, and IV fluids were difficult to locate. Multiple staff simultaneously called 911 (Fig 2), and the paramedics had difficulty distinguishing OPIC from the surrounding office buildings.
Several problem points identified:
1. Staff role delineation2. Medication and supply locations3. Medication dosing 4. Facility location identification
The Problem
The PDSA Method
1. Design an Emergency Response Poster to outline the steps of our new protocol
Benefits of this poster:• Standardized response protocol, per ACR Manual on Contrast Media2
• Staff role delineation – color coded for specific staff positions• Explicit medication dosing• Facility address to assist 911 callers
2. Designate location for the emergency response kit (medications, supplemental oxygen)
3. Install intercom system to facilitate rapid contact from CT/MRI to nursing4. Initiate regular mock drills to reinforce understanding of the protocol
5. Use a survey to measure success of the new protocol. Employ Likert scores (range 1-5; 1=not comfortable/unknown, 5 = very comfortable/well known). We aimed to achieve scores of 4-5 to demonstrate high competence with the protocol. The survey consisted of three questions:
i. How comfortable do you feel if you had to respond to an emergency in the imaging center?
ii. Do you know your role during an emergency response?iii. Do you know your resources if you have questions about the
emergency response procedure at the imaging center?
PLAN
The emergency protocol implementation was deemed successful based on
the persistent high comfort/understanding reflected on the QI survey (Fig 7). In fact, several weeks after the mock drill, the OPIC staff further proved their competence by using the protocol to efficiently and safely respond to a true contrast reaction. During the Act phase, the QI team initiated next steps:
1. Distributed copies of the poster throughout the remainder of OPIC2. Designated a technologist to replace the intercom battery quarterly3. Scheduled semi-annual mock drills to reinforce understanding of the
protocol and educate newly hired staff
Due to the success of our small scale project, our healthcare organization,
Banner Health, plans to widely disseminate similar emergency response
protocols within other departments. For example, inpatient and cancer center radiology areas, infusion, and inpatient nursing floors plan to adapt our protocol to emergency scenarios that are specific to their clinical areas.
ACT
Our emergency response QI project highlights several take home points for other institutions:
1. A successful PDSA cycle requires team engagement, measurable
data, and continuous improvement.
2. In an emergency situation, role delineation is critical to minimize
confusion and errors.
3. A standardized and simple protocol decreases variability in
emergency response, improves safety and team efficiency, and promotes adherence to professional organization guidelines.
Conclusions
Our quality improvement (QI) team employed the Plan-Do-Study-Act (PDSA) methodology to improve our emergency response process1. The
name of the method is self explanatory in regards to its four phases:
Plan = Develop a change to improve a processDo = Test the new change on a small scaleStudy = Analyze the test resultsAct = Determine if the change needs refinement. If so, initiate another PDSA iteration; if not, widely implement successful changes
Measureable data and documentation is key, since these results will
quantitatively dictate if the change is successful or requires improvement.
Pre- and post-intervention survey scores are as follows:
Mean Likert scores increased significantly after the initial protocol
review meeting (p < 0.0001 for all three survey questions). After the mock drill, mean Likert scores did not significantly change relative to the initial post-review meeting survey (p = 0.4, 0.49, 0.3, respectively).
In the study phase of the mock drill, the QI team discussed areas for improvement. We discovered that the intercom system had a nonfunctional battery.
1. Created the emergency response poster (Fig 3)2. Secure poster in critical locations in department (Fig 4)3. Location chosen for the emergency response kit in the nursing area (Fig 5)4. Intercom system purchased and deployed (Fig 6)5. Scheduled an OPIC team meeting to review the new protocol. Distribute the QI
survey before and immediately after the meeting.6. Performed a mock drill three months after the initial meeting to assess for
continued understanding. Distributed the QI survey after this mock drill.
DOSTUDY
Pre-Intervention (n=18)
Post-intervention immediately afterfirst meeting (n=18)
After mock drill (n=15)
Question1
Question 2
Question 3
Question1
Question 2
Question 3
Question1
Question 2
Question 3
Mean 2.9 3.1 3.7 4.6 4.9 5.0 4.8 4.9 4.9
SD 1.0 1.2 1.1 0.5 0.2 0.0 0.4 0.3 0.3
Fig 1. Distressed patient and staff confusion
Fig 2. Who calls 911?
Fig 3. OPIC emergency response poster
Fig 4. Poster (arrow) placed in CT room
Fig 6. Intercom (arrow) readily accessible for CT technologistsFig 5. Response kit and
oxygen stay in nursing area
Fig 7. Confident staff = safe, consistent, high quality care
Staff and Patient Safety is the Top Priority
CT Technologist: Keep CT Door to Hallway Open
MRI Technologist: BEFORE ENTRY EVERYONE: Pat down and Remove all metal on their person
Immediately MOVE patient safely to “Safe Zone" and secure door to MRI Room
“Safe Zone” is between CT and MRI. Keep door to Hallway Open
Only approved equipment allowed in MRI Room, any other requires Entech approval. NO OXYGEN TANKS in MRI ROOM
Medical Imaging Radiologist
Nurse/RN
Supervisor or designee
MRI and CT Technologist
Scheduler
Tech Aide
Mammo or Us Technologist
Banner Outpatient Imaging Center (OPIC)
Emergency Response Procedure
Contrast Media Reactions
Step 1 MRI or CT push “Call Button”
Step 2 Scheduler Vocera state (Broadcast Women’s Imaging) “Nurse Now”
3 times to CT/MRI
Step 3 Nurse/RN Assess patient andexecute physician's order set
Step 4 Tech Aide Vocera Supervisor or Designee
Step 5 Supervisor or Designee contact Radiologist
Step 6 Tech Aide bring Oxygen and Emergency Respiratory Supplies
Step 7 Nurse/RN
- Maintain airway - Support Breathing with supplemental oxygen apply O2 @ 2L/nasal
prongs - Apply Vital Signs Monitor and Pulse Oximetry (SPO2 <90%) - Initiate IV fluid bolus of 0.9% normal saline 250cc over 15minutes
Per orders of Radiologist give Benadryl (diphenhydramine) 50mg IVP
Per orders of Radiologist give Epinephrine dilution 1:1000 (1mg/ml)
0.3mg-1.0mg max) sub-q or IM.
Draw medication up in 1cc syringe give epinephrine in 0.1ml (100mcg/0.1ml) increments as ordered.
(Have epinephrine abbo-jet available 1:10,000 dilution/10ml. Give IV 1ml of 1:10,000 dilution (0.1mg); administer slowly into running IV infusion of saline flush: can repeat every few minutes as needed up to 10ml (1mg)
Per order of Radiologist give solu-cortef (hydrocortisone) 100mg IVP
Step 8 Supervisor or Designee will call 911 if condition deteriorates per discretion of RN/Radiologist
Patients name and age
Patient condition
Location address, phone number, and where on BGMC campus
Scheduler to wait for ambulance to guide ER rescue staff to patient location
Vaso-Vagal Reactions
Step 1 MRI or CT push “Call Button”
Scheduler Vocera state (Broadcast Women’s Imaging) “Nurse Now” 3 times to CT/MRI
Mammo or US Vocera (Broadcast Women’s
Imaging ) “Nurse Now” 3 times to location
Step 2 Trendelenburg position elevate legs
Step 3 Assess airway and breathing
Step 4 Cold compress
Step 5 Apply Vital Signs monitor and pulse oximetry
Step 6 Ammonia Inhalant
Step 7 If signs and symptoms resolve, continue with
procedure.
Step 8 Tech Aide Vocera Supervisor or Designee
Step 9 Tech Aide bring Oxygen and Emergency
Respiratory Supplies.
Step 10 Nurse/RN If signs and symptoms are not resolving
Initiate IV fluid bolus of normal saline 0.9% normal saline 250cc over 15 minutes.
If patient develops symptomatic bradycardia or hypotension RN to give Atropine 0.5—1.0mg max IVP Per order of Radiologist.
Step 11 Supervisor or Designee Call 911 if patient condition deteriorates per discretion of RN/Radiologist
Patients name and age
Patient condition
Location address, phone number, and where on BGMC campus
Scheduler to wait for ambulance to guide ER rescue staff to patient location
Contrast Extravasation
Step 1 Report to Imaging Radiologist:
- Type / Amount of contrast - Age of patient - General condition of affected extremity - Patient symptoms: pain, burning, swelling,
numbness, discoloration
Step 2 Mark boundaries of extravasation on skin
Step 3 Measure circumference of the extravasation
Step 4 Elevate extremity
Step 5 Apply cold compresses for 15 min on and 15 min
off; for 2 hours. ***Insulate patient's skin from cold compresses, with towel first
References: Banner Health Policy (10508) Emergency Response Authorization Order Set Adult Patients. Effective Date 2/13/2013
Banner Health Policy (14352) Contrast Media Reaction/Extravasation. Effective Date 2/3/2014
American College Radiology Manual (ACR) Management of Acute Reactions to Contrast Media in Adults Version 10/1/2015
MDA Imaging Center
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